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Fellowship Application

NORTH AMERICAN THROMBOSIS FORUM
TRAVELING FELLOWSHIP APPLICATION FOR 2010

*Note:  All applications and letters of recommendation must be completed and received in the NATF office by July 15, 2010.  Incomplete applications or those received after the deadline will not be considered.

INSTRUCTIONS:
  1. Applications can not be saved, you must submit the application after filling out the information.
    2.
  2. Candidate must be a resident of North America.
    3.
  3. Candidate must be a healthcare professional (MD, DO, PhD, PharmD, RPh NP, PA, or RN) or a scientist working in a health related field, preferably a junior faculty member or a professional-in-training.
  4. The following items constitute the complete application:
    1. This application form filled out with these attachments:
      1. Photograph
      2. Abbreviated CV (no longer than 4 pages)
      3. A personal statement
      4. Proof of North American citizenship or residency of Canada, Mexico or United States
    2. Two (2) letters of recommendation
    3. Letter of support from proposed host supervisor
    4. Letter of support from the proposed host supervisor which includes an outline of the agreed upon project, available resources, and supervisor's role
    5. Brief biographical sketch of supervisor and list his/her recent publications
    6. Personal statement
  5. Insert your personal statement of approximately 500-700 words into the application form where indicated. The following details should be included:
    1. Description and purpose of project
    2. Relationship and benefit of project to personal area of interest
    3. Basis for choice of sponsor
    4. How your involvement with the project advances the goals of NATF and how it will benefit NATF as an organization
  6. Attach proof of citizenship or residency of Canada, Mexico, or United States. Acceptable documents are:
    • Passport
    • Birth Certificate
    • Consular Report of Birth or Certification of Birth
    • Naturalization Certificate
    • Certificate of Citizenship
    • Driver's License
    • Utility Bill
    • Automobile, Life or Health Insurance Policy
    • Voter Registration
    • IRS Tax Report W-2 Form
    Please attached one of these document as either a scanned image (.jpg) or document (.doc or .pdf).
  7. Request two letters of recommendation (note: provide contact information for each sponsor in Section II in the application form). One letter should be requested from the Attending Physician, Senior Pharmacist, Nursing Director, or Lab Director under whose service you have done the majority of your residency, training, or research. The other letter can be requested from a health care professional or scientist familiar with your work. Letters of recommendation from the Directors of Training Programs or Fellowships are especially useful
  8. Important: a letter of support must also be requested from the supervisor of the Fellowship program that you are proposing to NATF. The letter should include information about how the sponsor will work with the Fellow.
  9. It is the applicant's responsibility to make sure all forms and letters are received in the NATF office by the specified deadline. Be assured that the NATF office will contact you as soon as one of your letters arrives in the office, but it is solely the applicant's responsibility to stay in touch with all sponsors to assure their letters arrive before the deadline.
  10. All letters of recommendation should be addressed and directed to Arthur A. Sasahara, MD, Chair, NATF Traveling Fellowship Committee. Original signed letters are to be mailed to the following address: North American Thrombosis Forum, 1620 Tremont Street, Suite 3022, Roxbury Crossing, MA 02120.
  11. If you have any questions about completing the application, please contact Ilene Sussman at (617) 525-8326, or email isussman@NATFonline.org.

    * Indicates required fields.  Applicants are encouraged to fill out all fields for completeness.

Section I:  CONTACT INFORMATION

APPLICANT INFORMATION
* First Name:        
Middle Name:        
* Last Name:        
* Home Phone:   Mobile Phone:  
* Age:   * Date of Birth (mm/dd/yyyy):  
* Place of Birth:   * Citizenship:  
* Home Address:  
* City:        
* State or Province:        
* ZIP or Postal Code:        
* Email:  
* Photo (Must be JPEG):  
Max .jpg file size: 500 KB
(Recommended size: 400px by 200px)
* Photo will be used for the purpose of publicity of selected Fellows; it will not be shared with judges prior to completion of selection process
WORK INFORMATION
Address:  
City:        
State or Province:        
ZIP or Postal Code:        
Office Phone:   Fax: 
Email:  
     

Section II:  LETTERS OF RECOMMENDATION

Name of two qualified references who will support this application

(Note: One letter should be requested from the Attending Physician, Senior Pharmacist, Nursing Director, or Lab Director under whose service you have done the majority of your residency, training, or research. The other letter can be requested from a health care professional or scientist familiar with your work. Letters of recommendation from the Directors of Training Programs or Fellowships are especially useful.)
First Letter of Recommendation
Name
Institution
Address
Office Phone
Email
Second Letter of Recommendation
Name
Institution
Address
Office Phone
Email

Section III:  LETTER OF SPONSORSHIP

A letter of support must also be requested from the supervisor of the Fellowship program that you are proposing to NATF. The letter should include information about how the sponsor will work with the Fellow.
Name
Institution
Address
Office Phone
Email

Section IV:  EDUCATION/TRAINING

EDUCATION/TRAINING
Graduate of:  
Date Graduated(mm/yyyy):     Degree Earned: 
 
Graduate of:  
Graduation Date (mm/yyyy):     Degree Earned: 
 
Graduate of:  
Graduation Date (mm/yyyy):     Degree Earned: 
 
Graduate of:  
Graduation Date (mm/yyyy):     Degree Earned: 
 

Section V:  POST GRADUATE TRAINING

POST GRADUATE TRAINING
Type of Education or Fellowship:  
Director:   From:  To: 
Location:  
 
Type of Education or Fellowship:  
Director:   From:  To: 
Location:  
 
Type of Education or Fellowship:  
Director:   From:  To: 
Location:  

SECTION VI:  PROFESSIONAL ACTIVITIES AND MEMBERSHIPS

PROFESSIONAL ACTIVITIES, PRESENTATIONS, or ORGANIZATIONAL MEMBERSHIPS
(provide name, location, month, year, as appropriate)
1. Activity/Organizational Membership:  
    Location:  
    Date (mm/yyyy):  
         
2. Activity/Organizational Membership:  
    Location:  
    Date (mm/yyyy):  
         
3. Activity/Organizational Membership:  
    Location:  
    Date (mm/yyyy):  
         
4. Activity/Organizational Membership:  
    Location:  
    Date (mm/yyyy):  

SECTION VII:  SPECIAL AWARDS AND HONORS

Special Awards and Honors (list special awards[s] you have received from college and beyond)

Section VIII:  AREAS OF INTEREST

What type of practice do you engage in or aspire to?
Academic:  
Community:  
Administrative:  
Other:  

Section IX:  CURRICULUM VITAE

* Attach your abbreviated Curriculum Vitae here (only 4-5 pages).  CV must be a Word Document with a .doc file extension.  The font of the document must be 10 pt with single line spacing.   Any other submittal will not be accepted.  Max file size is 500 KB. Information to be included:
  • Education
  • Post Graduate Training
  • Work history
  • Research Interests
  • If Applicable
    • Professional Society Memberships
    • Licensure and Certification
    • Honors and Awards Presentations
    • Professional Grants
    • Teaching Experience
    • Publications

Section X:  PERSONAL STATEMENT

* Complete a personal statement below. Statement must contain between 5,000 to 10,000 CHARACTERS in order to be submitted. Include:

  • Description and purpose of project
  • Relationship and benefit of project to personal area of interest
  • Basis for choice of sponsor
  • How your involvement with the project advances the goals of NATF and how it will benefit NATF as an organization

Personal Statement

Minimum 5,000 Characters.   

SECTION XI:  ATTACH PROOF OF NORTH AMERICAN CITIZENSHIP OR RESIDENCY OF CANADA, MEXICO OR UNITED STATES

Acceptable documents are:

  • Passport
  • Birth Certificate
  • Consular Report of Birth or Certification of Birth
  • Naturalization Certificate
  • Certificate of Citizenship
  • Driver's License
  • Utility Bill
  • Automobile, Life or Health Insurance Policy
  • Voter Registration
  • IRS Tax Report W-2 Form

  (max size: 2 MB)

    




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